Healthcare Provider Details

I. General information

NPI: 1053935122
Provider Name (Legal Business Name): MOHAMED FAROUK ELSISY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3243 E MURDOCK ST
WICHITA KS
67208-3052
US

IV. Provider business mailing address

2401 GILLHAM RD ATTN PROVIDER ENROLLMENT DEPT
KANSAS CITY MO
64108-4619
US

V. Phone/Fax

Practice location:
  • Phone: 316-500-8900
  • Fax:
Mailing address:
  • Phone: 816-701-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number04-52876
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: